CPT Code 99072: Reimbursement Challenges and Guidance

CPT_AMA Announces a New PPE code – But is it Payable

The American Medical Association (AMA) introduced a new CPT® code, aimed at covering additional provisions to ensure patient and provider safety during a public health emergency (PHE).

  • CPT 99072: Additional supplies, materials, and clinical staff time beyond what is typically included in an office visit or non-facility service(s), when performed during a PHE due to a respiratory-transmitted infectious disease.
  • Effective immediately upon publication.

CMS’s Stance on 99072 CPT Code

The Centers for Medicare & Medicaid Services (CMS) assigned CPT 99072 a procedure status of “B,” meaning:

  • The code has no Relative Value Units (RVUs).
  • It is bundled with the primary service provided on the same day.
  • CMS will not reimburse for this code separately.
  • Providers cannot bill patients for this service.
  • An Advance Beneficiary Notice (ABN) cannot be issued to collect payment from Medicare beneficiaries.

Reimbursement by Private Payers

While some third-party payers have reimbursed and will continue reimbursing for CPT 99072, others do not cover the service. The AMA’s CPT Editorial Panel creates CPT codes but does not influence payment policies. 

  • Time spent on CPT 99072 cannot overlap with other time-based services during the same encounter.
  • The code does not need to be linked to a specific diagnosis, such as ICD-10-CM U07.1 (COVID-19).
  • It may be reported with an Evaluation and Management (E/M) service or procedure but only once per in-person encounter per Provider Identification Number (PIN).

Challenges in Billing for PPE Costs

Given that most payers do not reimburse 99072 CPT Code, many providers are questioning how to handle PPE-related billing. Physicians should check with their Medicare contractors and insurance carriers for the latest reimbursement policies.

Here’s what we’ve found regarding commercial plan submissions:

  • Blue Cross Blue Shield (BCBS) North Carolina: CPT 99072 can be included on claims but is considered “incident to” the diagnosis or treatment, meaning it won’t be reimbursed separately.
  • BCBS Illinois: Approves $50 for CPT 99072 but requires billing as a separate line item alongside the physician office visit. Coverage is retroactive to September 1, 2020.
  • Advocate-Aurora Health Plan: Allows $10 per encounter for commercial HMO plans, starting January 1, 2021.
  • UnitedHealthcare (UHC) Texas: Considers PPE-related charges up to $15 when billed with CPT 99072.

Interestingly, dental practices have seen better reimbursement success, with many dental insurers reimbursing up to $30 per encounter for PPE-related expenses.

The HHS Perspective

The U.S. Department of Health and Human Services (HHS) may view its COVID-19 relief funding under the CARES Act as already covering additional PPE costs. Bundling 99072 CPT Code into E/M services aligns with this stance and protects Medicare and Medicaid patients from unexpected balance billing.

Final Recommendations 

Since commercial insurers are handling 99072 CPT Code differently, practices should:

  • Remove CPT 99072 from chargemasters for Medicare patients to prevent denials.
  • Verify private payer reimbursement policies before submitting claims to avoid balance billing surprises for patients. 
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